Provider Demographics
NPI:1215107974
Name:HAIR, DORA
Entity type:Individual
Prefix:
First Name:DORA
Middle Name:
Last Name:HAIR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 WESTHAVEN BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-5728
Mailing Address - Country:US
Mailing Address - Phone:601-922-8466
Mailing Address - Fax:601-488-0421
Practice Address - Street 1:1625 WESTHAVEN BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-5728
Practice Address - Country:US
Practice Address - Phone:601-922-8466
Practice Address - Fax:601-488-0421
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-09
Last Update Date:2008-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00422545376J00000X
MS01473740376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00422545Medicaid
MS01473740Medicaid